ECMO in cardiac arrest and cardiogenic shock

Prevalence and risk factors for in-hospital mortality of adult patients on veno-arterial extracorporeal membrane oxygenation for cardiogenic shock and cardiac arrest: A systematic review and meta-analysis

OBJECTIVES

To synthesize quantitative research findings on the prevalence and risk factors for in-hospital mortality of patients on veno-arterial extracorporeal membrane oxygenation (VA-ECMO).

METHODS

A comprehensive search was conducted for the period from May 2008 to December 2023 by searching the five electronic databases of PubMed, CINAHL, Web of Science, EMBASE, and Cochrane library. The quality of included studies was assessed using the Newcastle-Ottawa scale. The meta-analysis estimated the pooled odds ratio or standard mean difference and 95% confidence intervals.

RESULTS

A total of twenty-five studies with 10,409 patients were included in the analysis. The overall in-hospital mortality of patients on VA-ECMO was 56.7 %. In the subgroup analysis, in-hospital mortality of VA-ECMO for cardiogenic shock and cardiac arrest was 49.2 % and 75.2 %, respectively. The number of significant factors associated with an increased risk of in-hospital mortality in the pre-ECMO period (age, body weight, creatinine, chronic kidney disease, pH, and lactic acid) was greater than that in the intra- and post-ECMO periods. Renal replacement, bleeding, and lower limb ischemia were the most significant risk factors for in-hospital mortality in patients receiving VA-ECMO.

CONCLUSION

Early detection of the identified risk factors can contribute to reducing in-hospital mortality in patients on VA-ECMO. Intensive care unit nurses should provide timely and appropriate care before, during, and after VA-ECMO.

IMPLICATIONS FOR CLINICAL PRACTICE

Intensive care unit nurses should be knowledgeable about factors associated with the in-hospital mortality of patients on VA-ECMO to improve outcomes. The present findings may contribute to developing guidelines for reducing in-hospital mortality among patients considering ECMO.

What Are the Real Issues in Providing Extracorporeal Membrane Oxygenation (ECMO) Support: A Survey

INTRODUCTION

By using a novel survey our study aimed to assess the challenges ECMO and Critical Care (CC) teams face when initiating and managing patient's ECMO support.

METHODS

A qualitative survey-based observational study was performed of members of 2 Critical Care Medicine organizations involved in decision-making around the practice of Extracorporeal Membrane Oxygenation (ECMO). The range of exploratory questions covered ethical principles of informed consent, autonomy and goals of care discussions, beneficence, non-maleficence (offering life-sustaining treatments in end-of-life care), and justice (insurance-related limitations of treatment). Questions also covered pragmatic practice and quality improvement areas, such as exploring whether palliative care or ethics teams were involved in such decision-making.

RESULTS

305 members received the survey links, and a total of 61 completed surveys were received, for an overall response rate of 20% among all eligible members. Only 70% of the participants who manage ECMO patients are involved in the ECMO initiation decision process. The majority do not involve Ethics or Palliative care at the initial ECMO initiation decision step. Of the ethical and moral dilemmas reported, the majority revolved around 1. Prognostication of patients receiving VV and VA ECMO support, 2. Lack of knowledge of patient's wishes and goals, 3. Disconnect between expectations of families and outcomes and 4. Staff moral distress around when to stop ECMO in case of futility.

CONCLUSION

Our survey highlights areas of distress and dilemma which have been stressed before in the initiation, management, and outcomes of ECMO patients, however with the increasing use of this modality of cardiopulmonary mechanical support being offered, the survey results can offer a guidance using sound ethical principles.

Management of Myocardial Infarction and the Role of Cardiothoracic Surgery

Myocardial infarction (MI) is a leading cause of mortality globally and is predominantly attributed to coronary artery disease (CAD). MI is categorized as ST-elevation MI (STEMI) or non-ST-elevation MI (NSTEMI), each with distinct etiologies and treatment pathways. The goal in treatment for both is restoring blood flow back to the myocardium. STEMI, characterized by complete occlusion of a coronary artery, is managed urgently with reperfusion therapy, typically percutaneous coronary intervention (PCI). In contrast, NSTEMI involves a partial occlusion of a coronary artery and is treated with medical management, PCI, or coronary artery bypass grafting (CABG) depending on risk scores and clinical judgment. The Heart Team approach can assist in deciding which reperfusion technique would provide the greatest benefit to the patient and is especially useful in complicated cases. Despite advances in treatment, complications such as cardiogenic shock (CS) and ischemic heart failure (HF) remain significant. While percutaneous coronary intervention (PCI) is considered the primary treatment for MI, it is important to recognize the significance of cardiac surgery in treatment, especially when there is complex disease or MI-related complications. This comprehensive review analyzes the role of cardiac surgery in MI management, recognizing when it is useful, or not.

Soluble ST2 predicts continuous renal replacement therapy in patients receiving venoarterial extracorporeal membrane oxygenation

OBJECTIVE

This study aimed to evaluate the relationship between plasma soluble ST2 (sST2) levels 24 h after extracorporeal membrane oxygenation (ECMO) initiation and continuous renal replacement therapy (CRRT) in patients receiving venoarterial ECMO (V-A ECMO) support.

METHODS AND RESULTS

Data of patients who received ECMO support for postcardiotomy cardiogenic shock between January 2017 and July 2019 were retrospectively collected from Beijing Anzhen Hospital, Capital Medical University. Ultimately, 116 patients were included in the present study for analysis. The concentration of sST2 was determined by enzyme-linked immunosorbent assay (ELISA). The log10 sST2 levels were higher in patients undergoing CRRT than those who did not (6.06 vs. 6.22, p = 0.019). Patients undergoing CRRT had a lower survival rate than those who did not (32.8% vs. 67.3%, p < 0.001). In the univariate logistic regression analysis, sST2, HCO3-, lactate, and creatinine levels 24 h after ECMO initiation were related to CRRT (p < 0.05). In the multivariate logistic regression analysis, HCO3- and sST2 were identified as independent risk factors for CRRT use in patients undergoing ECMO (p < 0.05). The area under receiver operator characteristic curve (AUC) for sST2 and HCO3- together was 0.72 (95% confidence interval (CI), 0.79-0.91), which was better than those of sST2 or HCO3- alone (0.63 vs. 0.67).

CONCLUSIONS

sST2 and HCO3-levels at 24 h after ECMO initiation were associated with CRRT and could predict CRRT use in postcardiotomy cardiogenic shock patients undergoing ECMO.

Hypothermia in patients with cardiac arrest prior to ECMO-VA: Insight from the HYPO-ECMO trial

AIM

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has become a common intervention for patients with cardiogenic shock (CS), often complicated by cardiac arrest (CA). Moderate hypothermia (MH) has shown promise in mitigating ischemia-reperfusion injury following CA. The HYPO-ECMO trial aimed to compare the effect of MH versus normothermia in refractory CS rescued by VA-ECMO. The primary aim of this non-predefined post hoc study was to assess the treatment effect of MH in the subgroup of patients with cardiac arrest (CA) within the HYPO-ECMO trial. Additionally, we will evaluate the prognostic significance of CA in these patients.

METHODS

This post hoc analysis utilized data from the randomized HYPO-ECMO trial conducted across 20 French cardiac shock care centers between October 2016 and July 2019. Participants included intubated patients receiving VA-ECMO for CS for less than 6 h, with 334 patients completing the trial. Patients were randomized to early MH (33-34 °C) or normothermia (36-37 °C) for 24 h.

RESULTS

Of the 334 patients, 159 (48%) experienced preceding CA. Mortality in the CA group was 50.9% at 30 days and 59.1% at 180 days, compared to 42.3% and 51.4% in the no-CA group, respectively (adjusted risk difference [RD] at 30 days, 8.1% [-0.8 to 17.1%], p = 0.074 and RD at 180 days 7.0% [-3.0 to 16.9%], p = 0.17). MH was associated with a significant reduction in primary (RD -13.3% [-16.3 to -0.3%], p = 0.031) and secondary outcomes in the CA group only (p < 0.025 for all), with a significant interaction between MH and CA status for 180-day mortality [p = 0.03].

CONCLUSIONS

This post hoc analysis suggests that MH shows potential for reducing mortality and composite endpoints in patients with cardiac arrest and refractory CS treated with VA-ECMO without an increased risk of severe bleeding or infection. Further research is needed to validate these findings and elucidate underlying mechanisms.

Venoarterial Extracorporeal Life Support Use in Acute Pulmonary Embolism Shows Favorable Outcomes

BACKGROUND

Differences in outcomes by indication for venoarterial extracorporeal life support (VA-ECLS) are poorly described. We hypothesized that patients on VA-ECLS for acute pulmonary embolism (PE) have fewer complications and better survival than patients on VA-ECLS for other indications.

METHODS

All patients ≥18 years on VA-ECLS from the Extracorporeal Life Support Organization global registry (2010-2019) were evaluated (n = 29,842). After excluding patients aged >79 years (n = 729) and those with incomplete indication data (n = 2530), patients were stratified by VA-ECLS indication for PE vs all other indications. The association between being discharged alive and each type of complication with VA-ECLS indication was assessed.

RESULTS

Of 26,583 patients included in the analysis, 978 (3.7%) were on VA-ECLS for a primary diagnosis of acute PE. Acute PE patients were younger (53.1 vs 56.7 years, P < .001) and were more likely to be women (52.1% vs 32.3%, P < .001). Patients who underwent VA-ECLS for acute PE were 78% more likely to be discharged alive vs patients supported with VA-ECLS for other reasons (52.8% vs 40.4%; P < .001). Acute PE patients had fewer cardiovascular and renal complications (26.6% vs 38.0% and 31.1% vs 39.4%, respectively; adjusted P < .001). Acute PE patients had higher odds of having clots and mechanical complications (8.7% vs 7.9% and 16.7% vs 14.6%, respectively; adjusted P < .001).

CONCLUSIONS

Patients undergoing VA-ECLS for acute PE have higher odds of survival to hospital discharge compared with those supported for other indications. Additionally, VA-ECLS in this population is associated with fewer cardiovascular and renal complications but higher mechanical complications.

Aortic arch blood flow measurements as a predictor of successful ECMO weaning in cardiogenic shock

Objective

Acute cardiogenic shock is a life-threatening condition with mortality rates of up to 50%. If conventional therapy fails, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) therapy has emerged to a promising alternative for temporary cardiac and respiratory support in specialized centers. However, it is only a bridge to recovery, final decision, heart transplantation or the permanent implantation of a left ventricular assist device. Therefore, the identification of the optimum weaning time point is challenging, and standardized weaning protocols are rare.

Methods

In this explorative pilot study, we evaluated the potential benefit of blood flow measurements in the aortic arch using an ultrasonic cardiac output monitor (USCOM) for the primary endpoint of successful VA-ECMO weaning. 12 patients under VA-ECMO therapy for acute cardiogenic shock and a hemodynamic condition which qualified for a stepwise weaning process were included in this study. Main exclusion criterion was the presence of additional venting therapy for left ventricular unloading, e.g. Impella. Statistical comparisons were performed using the Mann-Whitney test and corrected for multiple testing by the Holm-Sidak method.

Results

Peak velocity of flow in the aortic arch showed a positive correlation with weaning success independent of ECMO flow (weaning success vs. failure: 0.75 vs. 0.35 m/s (low ECMO support), p = 0.049), whereas we identified only a trend for mean pressure gradient, minute distance and stroke volume index.

Conclusion

We hypothesize, that USCOM might provide an additive benefit to conventional strategies in its ability to predict successful VA-ECMO weaning and prevent pulmonary congestion. Larger upcoming trials are required to address this relevant topic and provide standardized treatment protocols for optimized weaning in the future.

The Jena Method: Perfusionist Independent, Standby Wet-Primed Extracorporeal Membrane Oxygenation (ECMO) Circuit for Immediate Catheterization Laboratory and/or Hybrid Operating Room Deployment

Background: The timely initiation of extracorporeal membrane oxygenation (ECMO) is crucial for providing life support. However, delays can occur when perfusionists are not readily available. The Jena Method aims to address this issue by offering a wet-primed ECMO system that can be rapidly established without the perfusionist's presence. Methods: The goal was to ensure prompt ECMO initiation while maintaining patient safety. The method focuses on meeting hygienic standards, safe primed storage of the circuit, staff training, and providing clear step-by-step instructions for the ECMO unit. Results: Since implementing the Jena Method in 2015, 306 patients received VA-ECMO treatment. Bacterial tests confirmed the sterility of the primed ECMO circuits during a 14-day period. The functionality of all the components of the primed ECMO circuit after 14 days, especially the pump and oxygenator, were thoroughly checked and no malfunction was found to this day. To train staff for independent ECMO initiation, a step-by-step system involves safely bringing the ECMO unit to the intervention site and establishing all connections. This includes powering up, managing recirculation, de-airing the system, and preparing it for cannula connection. A self-developed picture-based guide assists in this process. New staff members learn from colleagues and receive quarterly training sessions by perfusionists. After ECMO deployment, the perfusionist provides a new primed system for a potential next patient. Conclusions: Establishing a permanently wet-primed on-demand extracorporeal life support circuit without direct perfusionist support is feasible and safe. The Jena Method enables rapid ECMO deployment and has the potential to be adopted in emergency departments as well.

Visual analysis of the research literature on extracorporeal membrane oxygenation-assisted support for respiratory failure based on CiteSpace and VOSviewer: a 20-year study

Background

This study aims to visually assess the bibliometric status, current hotspots, and development trends in the field of extracorporeal membrane oxygenation (ECMO)-assisted support for respiratory failure through an examination of articles pertaining to ECMO-assisted support for respiratory failure.

Methods

A search was conducted on pertinent literature in the domain of ECMO-assisted support for respiratory failure published from 2003 to 2023, utilizing the Web of Science Core Collection (WOSCC) database. A bibliometric analysis was conducted using CiteSpace and VOSviewer visualization software to identify and assess associations between keywords, countries, institutions, authors, journals, and references.

Results

The present study incorporated a compilation of 1,901 pertinent articles. The United States published the maximum number of research articles in this field, and was closely followed by Germany and China. Furthermore, the University of Michigan was the leading institution in ECMO research. In this context, Daniel Brodie, an American expert, significantly contributed to this field and had published 107 related articles on the subject. Concurrently, active collaboration among ECMO researchers was also observed. Asaio Journal was the most prolific contributor, and Giles J. Peek, 2009, published in Lancet, comprised the most cited article in the field. Additionally, the analysis of keywords could be divided into three categories: (I) neonatal ECMO; (II) complications of ECMO; (III) ECMO application in coronavirus disease 2019 (COVID-19); (IV) application of point-of-care ultra sound in ECMO.

Conclusions

This study employed CiteSpace and VOSviewer to conduct a systematic literature review on ECMO-assisted support for respiratory failure from 2003 to 2023 in the Web of Science core database. The research outcomes in this domain were presented, offering researchers references for them to gain an accurate understanding of the current state of research and emerging trends in this field.

A risk score for predicting extracorporeal membrane oxygenation support before lung transplantation

Background

Extracorporeal membrane oxygenation (ECMO) has been increasingly used as life support for lung transplantation. However, there are no clinical risk models to predict whether ECMO support is required for lung transplantation. This study developed a simple risk score to predict the need for intraoperative ECMO in patients undergoing lung transplantation, identify high-risk patients who need ECMO support, and guide clinical interventions.

Methods

Patients, who underwent lung transplantation between January 1, 2016 and July 31, 2021, were systematically reviewed. All enrolled patients were divided in a ratio of 7:3 to establish the development and validation datasets. A risk score model was established using stepwise logistic regression and verified using bootstrapping and the split-sample method.

Results

A total of 248 patients who underwent lung transplants were enrolled. Multivariate analysis showed that the primary disease diagnosis, pulmonary artery systolic pressure, sex, surgical type, creatine kinase isoenzyme-MB, and pro-B-type natriuretic peptide were risk factors for intraoperative ECMO during lung transplantation. The risk score was established and calibrated according to these six factors, ranging from 0 to 41, with the associated prediction of intraoperative use of ECMO ranging from 1.5% to 99.7% (Hosmer-Lemeshow χ2=5.624; P=0.689). Good discrimination was verified by developing and validating the datasets (C-statistics =0.850 and 0.842, respectively). Based on the distribution of the scores, the three levels were classified as low-risk (0-10], moderate-risk (10-20], and high-risk (20-41].

Conclusions

This simple risk score model effectively predicts the need for intraoperative ECMO and stratifies high-risk patients who require ECMO support.

Inflammatory Progression in Patients Undergoing Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO) is identified as a novel therapeutic strategy that offers short-term support to the metabolism of the heart and lungs in humans. Recently, the clinical centers, which provide ECMO has increased rapidly worldwide. The indications for the use of ECMO in daily clinical practice were broadened dynamically. However, even with the widespread adoption of ECMO, it still remains significant morbidity and mortality, and the underlying mechanisms are still not elucidated. Notably, one of the vital complications during ECMO was proposed as the inflammatory progression within the extracorporeal circulation. via the development of inflammatory response, patients with ECMO may further suffer from systemic inflammatory response syndrome (SIRS), posing serious risks to human health. Recently, growing evidence confirmed that through exposure of blood into the ECMO circuit could lead to the stimulation of the immune system which also facilitated the inflammatory response and systemic impaired. In the current review, the pathological development of inflammatory progression in patients with ECMO is well-listed. Furthermore, the relationship between immune-related activation and the development of inflammation is also summarized, which may further help us to decide the therapeutic strategies in daily clinical practice.

The low hemoglobin levels were associated with mortality in post-cardiotomy patients undergoing venoarterial extracorporeal membrane oxygenation

BACKGROUND

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is used as a rescue strategy for patients with refractory post-cardiotomy cardiogenic shock (PCS). These patients often have varying degrees of reduced hemoglobin levels, and there are few detailed investigations about the impact of hemoglobin level on their mortality. The objective of this study was to evaluate whether hemoglobin levels at day 1 from VA-ECMO initiation were associated with in-hospital mortality.

METHODS

We performed a retrospective analysis of adult VA-ECMO patients over approximately a 2-year period. We divided patients into survival and death groups based on their clinical outcomes and compared the differences in parameters between the two groups. Multivariate logistic regression analyses were performed to estimate whether hemoglobin level was related to the mortality.

RESULTS

One hundred and sixteen patients were included in final analysis. There were 52 patients in the survival group and 64 in the death group. The patients were younger in the survival group than the death group (58 vs 63, p = .023). The median (IQR) hemoglobin level at day 1 was 80 (73-89) × g/L, and the median (IQR) RelΔ hemoglobin was 41% (32-48%). Survival patients had a higher hemoglobin level at day 1 and a lower RelΔ hemoglobin than the death patients (91 vs 76 g/L, p < .001; 35% vs 45%, p < .001). The multivariable logistic regression analyses showed that the low hemoglobin levels at day 1 were independently associated with in-hospital mortality (OR 0.808; 95% CI, 0.747-0.874; p < .001). The AUROC for hemoglobin level was 0.89 (95% CI, 0.83-0.95) which was better than that of RelΔ hemoglobin (0.77, 95% CI, 0.68-0.86).

CONCLUSIONS

In patients receiving VA-ECMO for PCS, the low hemoglobin levels at day 1 were independently associated with in-hospital mortality.

Impact of a VA-ECMO in Combination with an Extracorporeal Cytokine Hemadsorption System in Critically Ill Patients with Cardiogenic Shock-Design and Rationale of the ECMOsorb Trial

BACKGROUND

Cardiogenic shock and arrest present as critical, life-threatening emergencies characterized by severely compromised tissue perfusion and inadequate oxygen supply. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) serves as a mechanical support system for patients suffering shock refractory to conventional resuscitation. Despite the utilization of VA-ECMO, clinical deterioration due to systemic inflammatory response syndrome (SIRS) resulting from the underlying shock and exposure of blood cells to the artificial surfaces of the ECMO circuit may occur. To address this issue, cytokine adsorbers offer a valuable solution by eliminating blood proteins, thereby controlling SIRS and potentially improving hemodynamics. Consequently, a prospective, randomized, blinded clinical trial will be carried out with ECMOsorb.

METHODS AND STUDY DESIGN

ECMOsorb is a single-center, controlled, randomized, triple-blinded trial that will compare the hemodynamic effects of treatment with a VA-ECMO in combination with a cytokine adsorber (CytoSorb®, intervention) to treatment with VA-ECMO only (control) in patients with cardiogenic shock (with or without prior cardiopulmonary resuscitation (CPR)) requiring extracorporeal, hemodynamic support. Fifty-four patients will be randomized in a 1:1 fashion to the intervention or control group over a 36-month period. The primary endpoint of ECMOsorb is the improvement of the Inotropic Score (IS) 72 h after the intervention. Prognostic indicators, including mortality rates, hemodynamic parameters, laboratory findings, echocardiographic assessments, quality of life measurements, and clinical parameters, will serve as secondary outcome measures. The safety evaluation encompasses endpoints such as air embolisms, allergic reactions, peripheral ischemic complications, vascular complications, bleeding incidents, and stroke occurrences.

CONCLUSIONS

The ECMOsorb trial seeks to assess the efficacy of a cytokine adsorber (CytoSorb®; CytoSorbents Europe GmbH, Berlin, Germany) in reducing SIRS and improving hemodynamics in patients with cardiogenic shock who are receiving VA-ECMO. We hypothesize that a reduction in cytokine levels can lead to faster weaning from inotropic and mechanical circulatory support, and ultimately to improved recovery.

The effects of ECMO on neurological function recovery of critical patients: A double-edged sword

Extracorporeal membrane oxygenation (ECMO) played an important role in the treatment of patients with critical care such as cardiac arrest (CA) and acute respiratory distress syndrome. ECMO is gradually showing its advantages in terms of speed and effectiveness of circulatory support, as it provides adequate cerebral blood flow (CBF) to the patient and ensures the perfusion of organs. ECMO enhances patient survival and improves their neurological prognosis. However, ECMO-related brain complications are also important because of the high risk of death and the associated poor outcomes. We summarized the reported complications related to ECMO for patients with CA, such as north–south syndrome, hypoxic–ischemic brain injury, cerebral ischemia–reperfusion injury, impaired intracranial vascular autoregulation, embolic stroke, intracranial hemorrhage, and brain death. The exact mechanism of ECMO on the role of brain function is unclear. Here we review the pathophysiological mechanisms associated with ECMO in the protection of neurologic function in recent years, as well as the ECMO-related complications in brain and the means to improve it, to provide ideas for the treatment of brain function protection in CA patients.

Predictors of Mortality in Patients With Refractory Cardiac Arrest Supported With VA-ECMO: A Systematic Review and a Meta-Analysis

Cardiac arrest (CA) is associated with high mortality rate, ranging between 75% and 93%. Given its significance, venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been used for end-organs perfusion and to maintain adequate oxygenation as a life-saving option in refractory CA. The predictors for the success of VA-ECMO in this setting have not been established yet. In this meta-analysis, we aim to identify the variables associated with increased mortality in patients with CA supported with VA-ECMO. We conducted a systematic review and meta-analysis to evaluate mortality-predicting factors in patients with CA supported with VA-ECMO that were published between January 2000 and July 2022. To identify relevant articles, the MEDLINE (Pubmed, Ovid) and Cochrane Databases were queried with various combinations of our prespecified keywords, including VA-ECMO, CA, and mortality predictors. We performed a meta-analysis using a random-effects model to calculate the odds ratio (OR). We retrieved a total of 4476 records, out of which we included 10 observational studies in our study. A total of 931 patients were included in our study with the age range of 47-68 years, predominantly males (63.9%). The overall mortality was 69.4%. The predictors for mortality were age >65 (OR 4.61, 95% CI 1.63-13.03, P < 0.01), history of chronic kidney disease (OR 2.42, 95% CI 1.37-4.28, P < 0.01), cardiopulmonary resuscitation duration prior to ECMO > 40 minutes (OR 6.62 [95% CI 1.39, 9.02], P < 0.01), having an initial nonshockable rhythm (OR 2.62 [95% CI 1.85, 3.70], P < 0.01) and sequential organ failure assessment score >14 (OR 12.29, 95% CI 2.71-55.74, P <0.01). Regarding blood work, an increase in lactate by 5 mmol/L increased the odds of mortality by 121% (2 studies; OR 2.21 [95% CI 1.26, 3.86], P < 0.01; I2 = 0%) while the increase in lactate by 1 mmol/L increases odd of mortality by 15% (2 studies, OR 1.15 [95% CI 1.02, 1.31], P = 0.03, I = 0%), and an increase in creatinine by 1 mg/dL increased the odds of mortality by 225% (1 study; OR 3.25 [95% CI 1.22, 8.7], P = 0.02). Albumin was protective as for each 1 g/dL increase, the odds of mortality decreased by 68% (1 study; OR 0.32 [95% CI 0.14, 0.74], P < 0.01). Refractory CA requiring VA-ECMO has a high mortality. Predictors of mortality include age >65, history of chronic kidney disease, cardiopulmonary resuscitation duration prior to ECMO > 40 minutes, initial rhythm being non-shockable and Sequential Organ Failure Assessment score >14.

ECMO Retrieval Program: What Have We Learned So Far

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used for patients with cardiogenic shock or cardiac arrest. However, survival rates remain low. It is unclear to what extent ECMO patients benefit from the ECMO team learning curve. Therefore, we aimed to analyze our mobile ECMO program patients from the past seven years to evaluate if a learning curve benefits patients’ outcomes. We analyzed 111 patients from our databank who were supported with a VA-ECMO and brought to our hospital from January 2015 to December 2021. Patients were divided into two groups: survival (n = 70) and non-survival (n = 41). As expected, complications after ECMO implantation were more severe in the non-survivor group. The incidence of thromboembolic events (p = 0.002), hepatic failure (p < 0.001), renal failure (p = 0.002), dialysis (p = 0.002) and systemic inflammatory response syndrome (SIRS, p = 0.044) occurred significantly more often compared with the survivor group. We were able to show that despite our extensive experience in terms of ECMO retrieval program the high mortality and morbidity rates stay fairly the same over the years. This displays that we have to focus even more on patient selection and ECMO indication.

Multiparameters associated to successful weaning from VA ECMO in adult patients with cardiogenic shock or cardiac arrest: Systematic review and meta-analysis

Venoarterial extracorporeal membrane oxygenation (VA ECMO) is a form of temporary mechanical circulatory support and simultaneous extracorporeal gas exchange for acute cardiorespiratory failure, including refractory cardiogenic shock (CS) and cardiac arrest (CA). Few studies have assessed predictors of successful weaning (SW) from VA ECMO. This systematic review and meta-analysis aimed to identify a multiparameter strategy associated with SW from VA ECMO. PubMed and the Cochrane Library and the International Clinical Trials Registry Platform were searched. Studies reporting adult patients with CS or CA treated with VA ECMO published from the year 2000 onwards were included. Primary outcomes were hemodynamic, laboratory, and echocardiography parameters associated with a VA ECMO SW. A total of 11 studies (n=653) were included in this review. Pooled VA ECMO SW was 45% (95%CI: 39-50%, I2 7%) and in-hospital mortality rate was 46.6% (95%CI: 33-60%; I2 36%). In the SW group, pulse pressure [MD 12.7 (95%CI: 7.3-18) I2 = 0%] and mean blood pressure [MD 20.15 (95%CI: 13.8-26.4 I2 = 0) were higher. They also had lower values of creatinine [MD -0.59 (95%CI: -0.9 to -0.2) I2 = 7%], lactate [MD -3.1 (95%CI: -5.4 to -0.7) I2 = 89%], and creatine kinase [-2779.5 (95%CI: -5387 to -171) I2 = 38%]. And higher left and right ventricular ejection fraction, MD 17.9% (95%CI: -0.2-36.2) I2 = 91%, and MD 15.9% (95%CI 11.9-20) I2 = 0%, respectively. Different hemodynamic, laboratory, and echocardiographic parameters were associated with successful device removal. This systematic review demonstrated the relationship of multiparametric assessment on VA ECMO SW.

Identification of key programmed cell death-related genes and immune infiltration in extracorporeal membrane oxygenation treatment for acute myocardial infarction based on bioinformatics analysis

Background

Extracorporeal membrane oxygenation (ECMO) is an important clinical treatment for acute myocardial infarction (AMI) combined with cardiogenic shock, but the role of programmed cell death (PCD)-related genes in prognostication has not yet been investigated. Therefore, we explored the key prognostic biomarkers and immune infiltration in ECMO treatment in AMI combined with cardiogenic shock.

Methods

The GSE93101 dataset was analyzed from the Gene Expression Omnibus (GEO) database, and the expression levels of PCD-related genes in AMI under ECMO were identified. Differentially expressed PCD-related genes between successful and failed treatment samples were analyzed, and Least absolute shrinkage and selection operator (LASSO) logistic regression and random forest were used to screen PCD-related molecular markers for ECMO treatment in AMI combined with cardiogenic shock. Co-expressed regulatory network and enrichment functions of the hub PCD-related genes were performed. In addition, the single-sample gene set enrichment analysis (ssGSEA) algorithm was used to calculate the immune cell infiltration of the ECMO treatment samples.

Results

A total of 115 differentially expressed genes were identified from the GSE93101 dataset, and 76 genes were associated with PCD. Then, two hub PCD-related genes, Cell division cycle associated 7 (CDCA7), ankyrin repeat and SOCS box containing 13 (ASB13) were identified as prognostic markers of ECMO treatment in AMI combined with cardiogenic shock. The most significant Gene Ontology (GO) enriched terms of the co-expressed protein of ASB13 are related to post-translational protein modification, cullin-RING ubiquitin ligase complex, and cullin family protein binding, and the Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis showed that ubiquitin mediated proteolysis is the most enriched pathway. The results of GO and KEGG analysis in CDCA7 were mainly involved in DNA and cell cycle related activities and pathways. Moreover, we found that the successful treatment samples contained a lower proportion of nature killer T cells using immune infiltration analysis. Immune cell infiltration analysis revealed that ASB13 was positively correlated with natural killer cell (r = 0.591, p = 0.026), monocyte (r = 0.586, p = 0.028), and gamma delta T cell (r = 0.562, p = 0.036).

Conclusion

The results of this study showed that ASB13 and CDCA7 may contribute to the occurrence and progression of AMI with cardiogenic shock under ECMO.

Extracorporeal membrane oxygenation for cardiogenic shock: a meta-analysis of mortality and complications

BACKGROUND

Venoarterial extracorporeal membrane oxygenation (va-ECMO) is an advanced life support for critically ill patients with refractory cardiogenic shock. This temporary support bridges time for recovery, permanent assist, or transplantation in patients with high risk of mortality. However, the benefit of this modality is still subject of discussion and despite the continuous development of critical care medicine, severe cardiogenic shock remains associated with high mortality. Therefore, this work aims to analyze the current literature regarding in-hospital mortality and complication rates of va-ECMO in patients with cardiogenic shock.

METHODS

We conducted a systematic review and meta-analysis of the most recent literature to analyze the outcomes of va-ECMO support. Using the PRISMA guidelines, Medline (PubMed) and Scopus (Elsevier) databases were systematically searched up to May 2022. Meta-analytic pooled estimation of publications variables was performed using a weighted random effects model for study size.

RESULTS

Thirty-two studies comprising 12756 patients were included in the final analysis. Between 1994 and 2019, 62% (pooled estimate, 8493/12756) of patients died in the hospital. More than one-third of patients died during ECMO support. The most frequent complications were renal failure (51%, 693/1351) with the need for renal replacement therapy (44%, 4879/11186) and bleeding (49%, 1971/4523), bearing the potential for permanent injury or death. Univariate meta-regression analyses identified age over 60 years, shorter ECMO duration and presence of infection as variables associated with in-hospital mortality, while the studies reporting a higher incidence of cannulation site bleeding were unexpectedly associated with a reduced in-hospital mortality.

CONCLUSIONS

Extracorporeal membrane oxygenation is an invasive life support with a high risk of complications. We identified a pooled in-hospital mortality of 62% with patient age, infection and ECMO support duration being associated with a higher mortality. Protocols and techniques must be developed to reduce the rate of adverse events. Finally, randomized trials are necessary to demonstrate the effectiveness of va-ECMO in cardiogenic shock.

Acute Massive and Submassive Pulmonary Embolism: Historical Considerations/Surgical Techniques of Pulmonary Embolectomy/Novel Applications in Donor Lungs with Pulmonary Emboli

Pulmonary embolectomy has a chequered history but the quest to surgically treat a patient diagnosed with pulmonary embolism effectively spurred the development of cardiopulmonary bypass and a new dawn for cardiac surgery. The advent of cardiopulmonary bypass, extracorporeal membrane oxygenation, and computed tomography pulmonary angiogram has allowed rapid diagnosis and made surgical pulmonary embolectomy a relatively safe procedure that should be considered when indicated. Pulmonary emboli in donor lungs, often get rejected for transplantation. Ex vivo lung perfusion is among newly available technology with the ability to not only recondition marginal lungs but also treat donor lung pulmonary embolisms, effectively increasing the donor pool.

PRospective REgistry of PAtients in REfractory cardiogenic shock-The PREPARE CardShock registry

Aim

Cardiogenic shock (CS) is a hemodynamically complex multisystem syndrome associated with persistently high morbidity and mortality. As CS is characterized by progressive failure to provide adequate systemic perfusion, supporting end‐organ perfusion using mechanical circulatory support (MCS) seems intriguing. Since most patients with CS present in the catheterization laboratory, percutaneously implantable systems have the widest adoption in the field. We evaluated feasibility, outcomes, and complications after the introduction of a full‐percutaneous program for both the Impella CP device and venoarterial extracorporeal membrane oxygenator (VA‐ECMO).

Methods

PREPARE CardShock (PRospective REgistry of PAtients in REfractory cardiogenic shock) is a prospective single‐center registry, including 248 consecutive patients between May 2019 and April 2021, who underwent cardiac catheterization and displayed advanced cardiogenic shock. The median age was 70 (58–77) years and 28% were female. Sixty‐five percent of the cases had cardiac arrest, of which 66% were out‐of‐hospital cardiac arrest. A local standard operating procedure (SOP) indicating indications as well as relative and absolute contraindications for different means of MCS (Impella CP or VA‐ECMO) was used to guide MCS use. The primary endpoint was in‐hospital death and secondary endpoints were spontaneous myocardial infarction and major bleedings during the hospital stay.

Results

Overall mortality was 50.4% with a median survival of 2 (0–6) days. Significant independent predictors of mortality were cardiac arrest during the index event (odds ratio [OR] with 95% confidence interval [CI]: 2.53 [1.43–4.51]; p = 0.001), age > 65 years (OR: 2.05 [1.03–4.09]; p = 0.036]), pH < 7.30 (OR: 2.69 [1.56–4.66]; p < 0.001), and lactate levels > 2 mmol/L (OR: 4.51 [2.37–8.65]; p < 0.001).

Conclusions

Conclusive SOPs assist target‐orientated MCS use in CS. This study provides guidance on the implementation, validation, and modification of newly established MCS programs to aid centers that are establishing such programs.

Risk Factors of paediatric Venoarterial Extracorporeal Membrane Oxygenation-Related gastrointestinal bleeding after Open Heart Surgeries

OBJECTIVE

To analyze the risk factors for gastrointestinal (GI) bleeding in congenital heart disease (CHD) patients supported with venoarterial extracorporeal membrane oxygenation (V-A ECMO) after open heart surgery.

METHODS

A retrospective analysis was performed on children with (GI group: 26 cases) and without (control group: 122 cases) GI bleeding during ECMO at Shanghai Children's Medical Center from 2017 to 2020. Clinical data were analyzed and compared between groups to search for risk factors for GI bleeding.

RESULTS

A total of 148 cases were included in the study.The overall incidence of GI bleeding was 17.6% (26/148). The in-hospital mortality rate in the GI group was 61.5% (16/26) vs. 45.9% (56/122) in the control group. Twenty-six patients suffered cardiac arrest before ECMO support. The GI bleeding incidence among extracorporeal cardiopulmonary resuscitation (ECPR) patients was 50.0% (13/26) vs. 28.7 (35/122) among non-ECPR patients, P=0.035. The activated clotting time (ACT) was 201.40 s (180.47 to 247.27) in the GI group vs. 177.63 s (167.79 to 203.13) (P = 0.050) in the control group. The lowest antithrombin level (Min AT) was 27.00±13.07% vs. 37.62±15.18 (P=0.001). The pH and lactate levels before ECMO (Pre PH and Pre Lac) were lower in the GI group than in the control group. (7.31±0.23 vs. 7.35±0.17, P=0.035 and 12.2±6.11 vs. 7.78±6.67, P=0.003). Liver function during ECMO support was statistically worse in the GI group than in the control group. Multivariate analysis showed that Pre Lac (OR = 1.106 [1.018-1.202], P=0.0016) was an independent risk factor for GI bleeding. ROC analysis of Pre Lac and GI bleeding showed an area under the curve (AUC) of 0.700 (95% CI: 0.600-0.800, P=0.002) and a cutoff value of 9.30 mmol/L (sensitivity, 73.1%; specificity, 62.7%).

CONCLUSIONS

As the first study in this field, the probability of GI bleeding and related mortality were found to be high in children supported with V-A ECMO after open heart surgery. A higher lactate level before ECMO was an independent risk factor for GI bleeding.

The Role of Angiotensin II in Poisoning-Induced Shock-a Review

Background

Shock in drug poisoning is a life-threatening condition and current management involves fluid resuscitation and vasopressor therapy. Management is limited by the toxicity of high-dose vasopressors such as catecholamines. Clinical trials have shown the efficacy of angiotensin II as an adjunct vasopressor in septic shock. The aim of this review is to assess the use of angiotensin II in patients with shock secondary to drug overdose.

Methods

Medline (from 1946), Embase (from 1947) and PubMed (from 1946) databases were searched until July 2021 via OVID. Included studies were those with shock due to drug poisoning and received angiotensin II as part of their treatment regimen. Of the 481 articles identified, 13 studies (case reports and scientific abstracts) were included in the final analysis with a total of 14 patients. Extracted data included demographics, overdose drug and dosage, angiotensin II dosage, time of angiotensin II administration, haemodynamic changes, length of hospital stay, mortality, complications, cardiac function and other treatment agents used.

Results

Thirteen studies were included consisting of 6 case reports, 6 scientific abstracts and 1 case series. Overdose drugs included antihypertensives (n = 8), psychotropics (n = 4), isopropanol (n = 1) and tamsulosin (n = 1). Out of a total of 14 patients, 3 patients died. Ten patients had their haemodynamic changes reported. In terms of MAP or SBP changes, three patients (30%) had an immediate response to angiotensin II, four patients (40%) had responses within 30 min, one patient (10%) within two hours and two patients (20%) did not have their time reported. Two patients were shown to have direct chronotropic effects within 30 min of angiotensin II administration. The median hospital stay for patients was 5 days (IQR = 4). The time from overdose until angiotensin II administration ranged from 5 to 56 h. Other vasopressors used included phenylephrine, noradrenaline, adrenaline, vasopressin, dobutamine, dopamine, methylene blue and ephedrine. A median of 3 vasopressors were used before initiation of angiotensin II. Twelve patients received angiotensin II as their final treatment.

Conclusions

Angiotensin II may be useful as an adjunct vasopressor in treating shock secondary to drug poisoning. However, the current literature consisted of only very low-quality studies. To truly assess the utility of angiotensin II use in drug-induced poisoned patients, further well-designed prospective studies are required.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13181-022-00885-4.

Quality of Life and Mid-Term Survival in Patients Receiving Extracorporeal Membrane Oxygenation After Cardiac Surgery

There is a lack of data regarding mid-term outcomes of extracorporeal membrane oxygenation (ECMO) for refractory postcardiotomy cardiogenic shock (PCS). In this context, this research aimed to assess the mid-term survival and quality of life of PCS patients who receive ECMO by comparing them with cardiac surgery patients who do not receive ECMO. A retrospective analysis was performed on the clinical data of patients who had undergone ECMO treatment after cardiac surgery from January 2013 to June 2017 in a tertiary hospital (n = 102); non-ECMO patients who had undergone cardiac surgery and were discharged successfully were selected as the control group (n = 102). Survival and mid-term quality of life were assessed and compared through the Short-Form 36 (SF-36). Both groups were followed up by telephone, and SF-36 scores were obtained from the surviving patients. The data were available for 89 patients (87.3%) and 88 patients (86.3%) in the ECMO group and the control group, respectively. After discharge, the control group outperformed the ECMO group in survival (93.1% vs. 82.4%; p = 0.013). No significant differences in complications, all-cause mortality, first readmission for any cause, or work condition between the ECMO group and the control group were observed. The SF-36 scores in general health (GH) and vitality (VT) were significantly lower among the ECMO survivors (p < 0.05). The results of this study indicate that ECMO can provide acceptable mid-term survival with good quality of life for patients with refractory cardiogenic shock.

Hyperoxia and mortality in conventional versus extracorporeal cardiopulmonary resuscitation

PURPOSE

Hyperoxia has been associated with adverse outcomes in post cardiac arrest (CA) patients. Study-objective was to examine the association between hyperoxia and 30-day mortality in a mixed cohort of two different modes of Cardiopulmonary Resuscitation (CPR): Extracorporeal (ECPR) vs. Conventional (CCPR).

MATERIAL AND METHODS

In this retrospective cohort study of CA patients admitted to a tertiary level CA centre in Australia (over a 6.5-year time period) mean arterial oxygen levels (PaO₂) and episodes of extreme hyperoxia (maximum of mean PaO₂ ≥ 300 mmHg) were analysed over the first 8 days post CA.

RESULTS

One hundred and sixty-nine post CA patients were assessed (ECPR n = 79 / CCPR n = 90). Mean PaO₂-levels were higher in the ECPR vs CCPR group (211 mmHg ± 58.4 vs 119 mmHg ± 18.1; p < 0.0001) as was the proportion with at least one episode of extreme hyperoxia (74.7% vs 16.7%; p < 0.001). After adjusting for confounders and the mode of CPR any episode of extreme hyperoxia was independently associated with a 2.52-fold increased risk of 30-day mortality (OR: 2.52, 95% CI: 1.06-5.98; p = 0.036).

CONCLUSIONS

We found extreme hyperoxia was more common in ECPR patients in the first 8 days post CA and independently associated with higher 30-day mortality, irrespective of the CPR-mode.

Cardiogenic Shock and the Use of Percutaneous Mechanical Assist Devices

Percutaneous mechanical assist devices are used in patients with cardiogenic shock. The purpose of this article is to familiarize critical care nurses with the various types of percutaneous mechanical assist devices, including the intra-aortic balloon pump, the Impella device, extracorporeal membrane oxygenation, and the TandemHeart device. Each type of device requires specific nursing care. In a patient with cardiogenic shock, the monitoring, care, and interventions provided by an experienced critical care nurse can make the difference between survival and death.

Postcardiotomy Extracorporeal Membrane Oxygenation in Neonates

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) provides circulatory support in children with congenital heart disease, particularly in the setting of cardiopulmonary failure and inability to wean from cardiopulmonary bypass. This study summarized the clinical application of ECMO in the treatment of heart failure after cardiac surgery in neonates.

MATERIALS AND METHODS

Clinical data of 23 neonates who received ECMO support in our center from January 2017 to June 2019 were retrospectively analyzed.

RESULTS

Twenty-three neonates, aged from 0 to 25 days and weight between 2,300 and 4,500 g, with heart failure postcardiotomy were supported with ECMO. The successful weaning rate was 78.26% and discharge rate was 52.17%. Bleeding and residual malformation were the most common complications. The univariate analysis showed that nonsurvivors were related to the factors such as higher lactate value of ECMO 12 and 24 hours (p = 0.008 and 0.001, respectively), longer time to lactate normalization (p = 0.001), lactate > 10 mmol/L before ECMO (p = 0.01), lower weight (p = 0.01), longer ECMO duration (p = 0.005), lower platelet count (p = 0.001), more surgical site bleeding (p = 0.001), and surgical residual malformation (p = 0.04). Further logistic regression analysis revealed that higher lactate value of ECMO 24 hours (p = 0.003), longer ECMO duration (p = 0.015), and surgical site bleeding (p = 0.025) were independent risk factors.

CONCLUSION

ECMO was an effective technology to support the neonates with cardiopulmonary failure after open heart surgery. Control the lactate acidosis and surgical site bleeding event may be helpful for patients' recovery.

Extracorporeal Life Support for Cardiac Arrest and Cardiogenic Shock

The rising incidence and recognition of cardiogenic shock has led to an increase in the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). As clinical experience with this therapy has increased, there has also been a rapid growth in the body of observational and randomized data describing the clinical and logistical considerations required to institute a VA-ECMO program with successful clinical outcomes. The aim of this review is to summarize this contemporary data in the context of four key themes that pertain to VA-ECMO programs: the principles of patient selection; basic hemodynamic and technical principles underlying VA-ECMO; contraindications to VA-ECMO therapy; and common complications and intensive care considerations that are encountered in the setting of VA-ECMO therapy.

Updates on the Management of Neurologic Complications of Post-Cardiac Arrest Resuscitation

Sudden cardiac arrest (SCA) is one of the leading causes of mortality and morbidity in the United States, and survivors are frequently left with severe disability. Of the 10% successfully resuscitated from SCA, only around 10% of these live with a favorable neurologic outcome. Survivors of SCA commonly develop post-cardiac arrest syndrome (PCAS). PCAS is composed of neurologic, myocardial, and systemic injury related to inadequate perfusion and ischemia-reperfusion injury with free radical formation and an inflammatory cascade. While targeted temperature management is the cornerstone of therapy, other intensive care unit-based management strategies include monitoring and treatment of seizures, cerebral edema, and increased intracranial pressure, as well as prevention of further neurologic injury. In this review, we discuss the scientific evidence, recent updates, future prospects, and knowledge gaps in the treatment of post-cardiac arrest patients.

Effect of arterial oxygen partial pressure inflection point on Venoarterial extracorporeal membrane oxygenation for emergency cardiac support

Background

Temporary circulatory support is a bridge between acute circulatory failure and definitive treatment or recovery. Currently, venoarterial extracorporeal membrane oxygenation (VA-ECMO) is considered to be one of the effective circulatory support methods, although cardiac function monitoring during the treatment still needs further investigation. Inflection point of arterial oxygen partial pressure (IPPaO2) may occur at an early stage in part of patients with a good prognosis after VA-ECMO treatment, and the relationship between time of IPPaO2 (tIPPaO2) and recovery of cardiac function or prognosis remains unclear.

Methods

To investigate this relationship, we retrospectively analyzed the clinical data of 71 patients with different conditions after treatment with VA-ECMO in the emergency center of Jiangsu Province Hospital between May 2015 and July 2020. Spearman’s correlation analysis was used for the correlation between tIPPaO₂ and quantitative data, and ROC curve for the predictive effect of tIPPaO₂ on the 28-day mortality.

Results

Thirty-five patients were admitted because of refractory cardiogenic shock (26 of 35 survived) and the remaining 36 patients due to cardiac arrest (13 of 36 survived). The overall survival rate was 54.9% (39 of 71 survived). Acute physiology and chronic health evaluation II, ECMO time, tIPPaO2, continuous renal replacement therapy time, mechanical ventilation time, and bleeding complications in the survival group were lower than those in the non-survival group, with length of stay, intensive care unit stay, and platelet levels were being higher. The tIPPaO₂ was negatively correlated with ejection fraction, and the shorter tIPPaO2 resulted in a higher 28-day survival probability, higher predictive value for acute myocardial infarction and fulminant myocarditis.

Conclusions

Therefore, tIPPaO2 could be a reliable qualitative indicator of cardiac function in patients treated with VA-ECMO, which can reveal appropriate timing for adjusting VA-ECMO flow or weaning.

Trial registration

ChiCTR1900026105.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00902-5.

Opportunities, controversies, and challenges of extracorporeal hemoadsorption with CytoSorb during ECMO

Extracorporeal membrane oxygenation (ECMO) is frequently used in many centers around the globe for various indications. However, prognosis is often poor even with all supportive therapies, and in many cases, clinical deterioration is associated with inflammation. Hemoadsorption with CytoSorb is a novel approach to limit the inflammatory response, and the device can be safely and easily installed into ECMO circuits. CytoSorb has been used more than 130.000 times to date, but because randomized controlled trials are largely lacking, there is substantial debate on its use. Here, experts from critical care medicine, cardiology, cardiac surgery, and perfusion technology discuss the pros and cons of this novel therapy and outline the future aspects for its clinical application and research.

Nomogram to predict survival outcome of patients with veno-arterial extracorporeal membrane oxygenation after refractory cardiogenic shock

Objective: This study aims to develop a nomogram model to predict the survival of refractory cardiogenic shock (RCS) patients that received veno-arterial extracorporeal membrane oxygenation (VA-ECMO).Methods: A total of 235 and 209 RCS patients were supported with VA-ECMO from January 2018 to December 2019 in Guangdong Provincial People's Hospital, and from January 2020 to December 2020 in four third-grade and class-A hospitals were a development cohort (DC) and validation cohort (VC), respectively. Finally, 137 and 98 patients were included in the DC and VC. Multivariate logistic regression analysis was used to identify variables, and only these independent risk factors were used to establish the nomogram model. The receiver operating characteristic curve (ROC), calibration plot, decision curve, and clinical impact curves were used to evaluate the nomogram's discriminative ability, predictive accuracy, and clinical application value.Results: Pre-ECMO cardiogenic arrest (pre-ECA), lactate (Lac), inotropic score (IS), and modified nutrition risk in the critically ill score (mNUTRIC score) were incorporated into the nomogram. This showed good discrimination in the DC, with an area under ROC (AUROC) and a 95% confidence interval (CI) of 0.959 (0.911-0.986). The AUROC (95% CI) of the VC was 0.928 (0.858-0.971). The calibration plots of the DC and VC presented good calibration results. The decision curve and clinical impact curve of the nomogram provided improved benefits for RCS patients.Conclusions: This study established a prediction nomogram composed of pre-ECA, Lac, IS, and mNUTRIC scores that could help clinicians to predict the survival probability at hospital discharge precisely and rapidly for RCS patients that received VA-ECMO.

Prevention and treatment of pulmonary congestion in patients undergoing venoarterial extracorporeal membrane oxygenation for cardiogenic shock

Cardiogenic shock is still a major driver of mortality on intensive care units and complicates ∼10% of acute coronary syndromes with contemporary mortality rates up to 50%. In the meantime, percutaneous circulatory support devices, in particular venoarterial extracorporeal membrane oxygenation (VA-ECMO), have emerged as an established salvage intervention for patients in cardiogenic shock. Venoarterial extracorporeal membrane oxygenation provides temporary circulatory support until other treatments are effective and enables recovery or serves as a bridge to ventricular assist devices, heart transplantation, or decision-making. In this critical care perspective, we provide a concise overview of VA-ECMO utilization in cardiogenic shock, considering rationale, critical care management, as well as weaning aspects. We supplement previous literature by focusing on therapeutic issues related to the vicious circle of retrograde aortic VA-ECMO flow, increased left ventricular (LV) afterload, insufficient LV unloading, and severe pulmonary congestion limiting prognosis in a relevant proportion of patients receiving VA-ECMO treatment. We will outline different modifications in percutaneous mechanical circulatory support to meet this challenge. Besides a strategy of running ECMO at lowest possible flow rates, novel therapeutic options including the combination of VA-ECMO with percutaneous microaxial pumps or implementation of a venoarteriovenous-ECMO configuration based on an additional venous cannula supplying towards pulmonary circulation are most promising among LV unloading and venting strategies. The latter may even combine the advantages of venovenous and venoarterial ECMO therapy, providing potent respiratory and circulatory support at the same time. However, whether VA-ECMO can reduce mortality has to be evaluated in the urgently needed, ongoing prospective randomized studies EURO-SHOCK (NCT03813134), ANCHOR (NCT04184635), and ECLS-SHOCK (NCT03637205). These studies will provide the opportunity to investigate indication, mode, and effect of LV unloading in dedicated sub-analyses. In future, the Heart Teams should aim at conducting a dedicated randomized trial comparing VA-ECMO support with vs. without LV unloading strategies in patients with cardiogenic shock.

Extracorporeal membrane oxygenation as a bridge to durable left ventricular assist device implantation in INTERMACS-1 patients

Left ventricular assist devices (LVADs) are increasingly used as destination therapy or as a bridge to future cardiac transplant in patients with end-stage heart failure. Extracorporeal membrane oxygenation (ECMO) can be used to bridge patients in cardiogenic shock or with decompensated heart failure to durable mechanical circulatory support. We assessed outcomes in patients in critical cardiogenic shock (Interagency Registry for Mechanically Assisted Circulatory Support [INTERMACS] profile 1) who underwent implantation of a continuous-flow (CF)-LVAD, with or without preoperative ECMO bridging. For this retrospective study, we selected INTERMACS profile 1 patients who underwent CF-LVAD implantation at our institution between Sep 1, 2004 and Nov 30, 2018. Of 768 patients identified, 133 (17.3%) were INTERMACS profile 1; 26 (19.5%) received preoperative ECMO support, and 107 (80.5%) did not. Postimplantation outcomes were compared between the ECMO and no-ECMO groups. No significant differences were found in 30-day mortality (15.4 vs. 15.9%, P = 0.95) or survival at 1 year (53.8 vs. 60.9%, P = 0.51). Three patients who received ECMO before CF-LVAD implantation subsequently underwent cardiac transplant. In the ECMO group, the lactate level 1 day after ECMO initiation was lower in survivors than nonsurvivors (2.7 ± 2.2 vs. 7.4 ± 4.2 mmol/L, P = 0.02; area under the curve = 0.85, P = 0.01) after CF-LVAD implantation. Bridging with ECMO to CF-LVAD implantation in carefully selected INTERMACS profile 1 patients (those who are at the highest risk for critical cardiogenic shock and for whom palliation may be the only other option) produced acceptable postoperative outcomes.Field of research: Artificial lung/ECMO.

Emergency department extracorporeal membrane oxygenation may also include noncardiac arrest patients

Background/aim

The primary purpose of this study is to report the experience on the extracorporeal membrane oxygenation (ECMO) process for patients in the critical care unit (CCU) of an emergency department of a tertiary hospital in Turkey, from cannulation to decannulation, including follow-up procedures.

Materials and methods

This retrospective and observational study included eight patients who received ECMO from January 2018 to January 2020. We evaluated the demographics, indications for ECMO, laboratory values, Respiratory ECMO Survival Prediction, Survival After Veno-Arterial ECMO and ECMO net scores, the management process, and patient outcomes. Blood gas analyses done after the first hour of ECMO initiation and the reevaluation of the patients’ Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores in the 24th hour of ECMO were recorded.

Results

The mean age was 52.7 ± 14.2 years. The median duration of the ECMO run was 81 (min–max: 4–267) h, and the mean length of CCU stay was 10.2 ± 6.7 days. Of the 8 patients studied, 5 (62.5%) had veno-arterial and 3 (37.5%) had veno-venous ECMO. Three patients were successfully weaned (37.5%). The overall survival-to-discharge rate was 25%. Carbon dioxide levels were significantly decreased 1 h after ECMO initiation (P = 0.038) as well as the need for vasopressors. Lactate levels were lower in decannulated patients. Changes in the APACHE II score were more consistent with the clinical deterioration in patients than SOFA score changes were.

Conclusions

In the early phase of ECMO, vital signs improve, and the need for vasopressors and carbon dioxide levels decrease. Thus, CCUs in Emergency Departments with ECMO capabilities could potentially be designed, and emergency department ECMO algorithms could be tailored for critically ill patients in addition to out-of-hospital cardiac arrest patients.

Urgent coronary artery bypass graft surgery supported by veno-arterial extracorporeal membrane oxygenation: a report of two cases

Mechanical circulatory support (MCS) devices, especially veno-arterial extracorporeal membrane oxygenation (VA-ECMO) devices, are increasingly used to shore complex cardiac procedures in high-risk patients. We are reporting two cases where patients underwent coronary artery bypass grafting (CABG) under support of VA-ECMO in the setting of cardiogenic shock complicating acute myocardial infarction. The patients had different courses, but both survived the initial insult and were weaned successively from VA-ECMO. Our report indicates that VA-ECMO can be used instead of the cardiopulmonary bypass machine (CPB) to support the circulation during CABG surgery in patients with complex coronary anatomy and unstable haemodynamics. Future studies focusing on the long-term outcomes of such patients will probably help to establish the optimal management of this type of patients.

Impact of Lactate Clearance on Early Outcomes in Pediatric ECMO Patients

Background and Objectives: Pediatric extracorporeal membrane oxygenation (ECMO) support is often the ultimate therapy for neonatal and pediatric patients with congenital heart defects after cardiac surgery. The impact of lactate clearance in pediatric patients during ECMO therapy on outcomes has been analyzed. Materials andMethods: We retrospectively analyzed data from 41 pediatric vaECMO patients between January 2006 and December 2016. Blood lactate and lactate clearance have been recorded prior to ECMO implantation and 3, 6, 9 and 12 h after ECMO start. Receiver operating characteristic (ROC) analysis was used to identify cut-off levels for lactate clearance. Results: Lactate levels prior to ECMO therapy (9.8 mmol/L vs. 13.5 mmol/L; p = 0.07) and peak lactate levels during ECMO support (10.4 mmol/L vs. 14.7 mmol/L; p = 0.07) were similar between survivors and nonsurvivors. Areas under the curve (AUC) of lactate clearance at 3, 9 h and 12 h after ECMO start were significantly predictive for mortality (p = 0.017, p = 0.049 and p = 0.006, respectively). Cut-off values of lactate clearance were 3.8%, 51% and 56%. Duration of ECMO support and respiratory ventilation was significantly longer in survivors than in nonsurvivors (p = 0.01 and p < 0.001, respectively). Conclusions: Dynamic recording of lactate clearance after ECMO start is a valuable tool to assess outcomes and effectiveness of ECMO application. Poor lactate clearance during ECMO therapy in pediatric patients is a significant marker for higher mortality.

Balanced Biventricular Assist Versus Extracorporeal Membrane Oxygenation in Cardiac Arrest

Mechanical assist devices in refractory cardiac arrest are increasingly employed. We compared the hemodynamics and organ perfusion during cardiac arrest with either veno-arterial extracorporeal membrane oxygenation (ECMO) or biventricular assisted circulation combining left- and right-sided impeller devices (BiPella) in an acute experimental setting. Twenty pigs were randomized in two equal groups receiving circulatory support either by ECMO or by BiPella during 40 minutes of ventricular fibrillation (VF) followed by three attempts of cardioversion, and if successful, 60 minute observation with spontaneous, unsupported circulation. Hemodynamic variables were continuously recorded. Tissue perfusion was evaluated by fluorescent microsphere injections. Cardiac function was visualized by intracardiac echocardiography. During VF device output, carotid flow, kidney perfusion, mean aortic pressure (AOPmean), and mean left ventricular pressure (LVPmean) were all significantly higher in the ECMO group, and serum-lactate values were lower compared with the BiPella group. No difference in myocardial or cerebral perfusion was observed between groups. In 15 animals with sustained cardiac function for 60 minutes after return of spontaneous circulation, left ventricular subendocardial blood flow rate averaged 0.59 ± 0.05 ml/min/gm during VF compared with 0.31 ± 0.07 ml/min/gm in five animals with circulatory collapse (p = 0.005). Corresponding values for the midmyocardium was 0.91 ± 0.06 vs. 0.65 ± 0.15 ml/min/gm (p = 0.085). Both BiPella and ECMO could sustain vital organ function. ECMO provided a more optimal systemic circulatory support related to near physiologic output. Myocardial tissue perfusion and sustained cardiac function were related to coronary perfusion pressure during VF, irrespective of mode of circulatory support.

Right-Left Ventricular Interaction in Left-Sided Heart Failure With and Without Venoarterial Extracorporeal Membrane Oxygenation Support-A Simulation Study

Left ventricular (LV) dilatation is commonly seen with LV failure and is often aggravated during venoarterial extracorporeal membrane oxygenation (VA ECMO). In this context, the intricate interaction between left and right heart function is considered to be of pivotal importance, yet mechanistically not well understood. We hypothesize that a preserved or enhanced right heart contractility causes increased LV loading both with and without VA ECMO. A closed-loop in-silico simulation model containing the cardiac chambers, the pericardium, septal interactions, and the pulmonary and systemic vascular systems with an option to connect a simulated VA ECMO circuit was developed. Right ventricular contractility was modified during simulation of severe LV failure with and without VA ECMO. Left atrial pressures increased from 14.0 to 23.8 mm Hg without VA ECMO and from 18.4 to 27.0 mm Hg under VA ECMO support when right heart contractility was increased between end-systolic elastance 0.1 and 1.0 mm Hg/ml. Left-sided end-diastolic volumes increased from 125 to 169 ml without VA ECMO and from 150 to 180 ml with VA ECMO. Simulations demonstrate that increased diastolic loading of the LV may be driven by increased right ventricular contractility and that left atrial pressures cannot be interpreted as a reflection of the degree of LV dysfunction and overload without considering right ventricular function. Our study illustrates that modelling and computer simulation are important tools to unravel complex cardiovascular mechanisms underlying the right-left heart interdependency both with and without mechanical circulatory support.

Successful resuscitation of acute cardiogenic shock presenting as ventricular fibrillation via Bipella approach: a case report

BACKGROUND

The use of mechanical circulatory support (MCS) in acute myocardial infarction and cardiogenic shock (AMICS) complicated by biventricular failure is poorly discussed in the literature.

CASE SUMMARY

We present successful treatment of a 52-year-old old man presenting with AMICS following cardiac arrest and prolonged CPR via a Bipella approach for biventricular support and restoration of haemodynamic stability.

DISCUSSION

This case demonstrates the importance of understanding the role of MCS in the management of cardiogenic shock; the value of the cardiac power output and pulmonary artery pulsatility index as haemodynamic metrics to assess the cardiac function of a patient with cardiogenic shock; and the importance of a Bipella MCS approach in high inpatient morbidity and mortality AMICS with biventricular failure.

Venoarterial Extracorporeal Membrane Oxygenation as an Effective Therapeutic Support for Refractory Cardiac Arrest in the Setting of Spinal Anesthesia: A Case Report and Literature Review

Cardiac arrest is the most serious event among the complications associated with spinal anesthesia. Spinal anesthesia reduces the release of catecholamines and impairs neuroendocrine response following cardiac arrest, which contributes cardiopulmonary resuscitation (CPR) more difficult. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) may be a bridge to provide a more effective and durable mechanical solution under this extremely critical condition. This study reports a 50-year-old man who was scheduled to undergo surgical great saphenous vein varices under spinal anesthesia. A sudden cardiac arrest occurred after spinal anesthesia. Standard CPR was performed and large doses of vascular drugs are administered, but the effect of resuscitation was still poor. We fastly initiated VA-ECMO to provide cardiopulmonary support for this refractory cardiac arrest. Fortunately, the patient was successfully resuscitated with complete recovery. In summary, standard CPR might more difficult during spinal block anesthesia. Quick-started VA-ECMO is a potential option under this situation, which protects the patient from further harm from repeated prolonged CPR, refractory hypotension and deteriorated desaturation, and therefore benefit for patient in this critical condition.

Methylene Blue for Vasoplegia During Extracorporeal Membrane Oxygenation Support

OBJECTIVE

The treatment of refractory vasodilatory shock in patients undergoing extracorporeal membrane oxygenation (ECMO) is an area in which there is minimal literature. Based on previous literature, the authors hypothesized that at least 40% of ECMO patients with vasoplegia would respond positively to methylene blue (MB) administration and that those who responded to MB would have increased survival.

DESIGN

Retrospective observational study.

SETTING

Single institution, quaternary care hospital.

PARTICIPANTS

The study comprised 45 patients who received MB for vasoplegia during ECMO.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the 45 patients who received MB, 25 patients (55.6%) experienced a ≥10% increase in mean arterial pressure (MAP) and a reduction in norepinephrine dosing in the one-to-two hour interval after MB administration. There was a trend for improvement in survival to discharge for those who responded to MB (32% v 10%; p = 0.15). In addition, patients who did not have at least a >5% increase in MAP (29 experienced a >5% increase and 16 experienced a ≤5% increase) after MB administration, experienced 100% mortality (p = 0.008).

CONCLUSION

This study suggested that approximately 50% of ECMO patients with vasoplegia can be expected to respond to MB with a >10% MAP improvement. The lack of a blood pressure response >5% after MB administration may portend poor survival. Larger prospective studies are needed to verify these preliminary results.

The clinical significance of blood lactate levels in evaluation of adult patients with veno-arterial extracorporeal membrane oxygenation

BACKGROUND

Veno-arterial ECMO is a life-supporting procedure that can be done to the patients with cardiogenic shock which is associated with hyperlactatemia. The objective of this study was to detect the validity of serial measurements of arterial lactate level in differentiating hospital mortality and neurological outcome after VA-ECMO support for adult patients with cardiogenic shock. All consecutive patients ≥ 18 years admitted with cardiogenic shock and supported with VA-ECMO between 2015 and 2019 in our tertiary care hospital were retrospectively studied.

RESULTS

The study included 106 patients with a mean age of 40.2 ± 14.4 years, a mean BMI of 26.5 ± 7 and mostly males (69.8%). The in-hospital mortality occurred in 56.6% and acute cerebral strokes occurred in 25.5% of the enrolled patients. The non-survivors and the patients with acute cerebral strokes had significantly higher arterial lactate levels at pre-ECMO initiation, post-ECMO peak and after 24 h of ECMO support compared to the survivors and those without strokes, respectively. The peak arterial lactate ≥ 14.65 mmol/L measured after ECMO support had 81.7% sensitivity and 89.1% specificity for predicting hospital mortality [AUROC 0.889, p < 0.001], while the arterial lactate level ≥ 3.25 mmol/L after 24 h of ECMO support had 88.3% sensitivity and 97.8% specificity for predicting hospital mortality [AUROC 0.93, p < 0.001]. The peak lactate ≥ 15.15 mmol/L measured after ECMO support had 70.8% sensitivity and 69% specificity for predicting cerebral strokes [AUROC 0.717, p < 0.001], while the lactate level ≥ 3.25 mmol/L after 24 h of ECMO support had 79.2% sensitivity and 72.4% specificity for predicting cerebral strokes [AUROC 0.779, p < 0.001]. Progressive hyperlactatemia (OR = 1.427, 95% CI 1.048-1.944, p = 0.024) and increasing SOFA score after 48 h (OR = 1.819, 95% CI 1.374-2.409, p < 0.001) were significantly associated with in-hospital mortality after VA-ECMO support. Post hoc analysis detected a significantly high frequency of hypoalbuminemia in the non-survivors and in the patients who developed acute cerebral strokes during VA-ECMO support.

CONCLUSION

Progressive hyperlactatemia after VA-ECMO initiation for adult patients with cardiogenic shock is a sensitive and specific predictor of hospital mortality and acute cerebrovascular strokes. According to our results, we could recommend early VA-ECMO initiation to achieve adequate circulatory support and better outcome.

A walk through the progression of resuscitation medicine

Cardiac arrest (CA) is a sudden and devastating disease process resulting in more deaths in the United States than many cancers, metabolic diseases, and even car accidents. Despite such a heavy mortality burden, effective treatments have remained elusive. The past century has been productive in establishing the guidelines for resuscitation, known as cardiopulmonary resuscitation (CPR), as well as developing a scientific field whose aim is to elucidate the underlying mechanisms of CA and develop therapies to save lives. CPR has been successful in reinitiating the heart after arrest, enabling a survival rate of approximately 10% in out-of-hospital CA. Although current advanced resuscitation methods, including hypothermia and extracorporeal membrane oxygenation, have improved survival in some patients, they are unlikely to significantly improve the national survival rate any further without a paradigm shift. Such a change is possible with sustained efforts in the basic and clinical sciences of resuscitation and their implementation. This review seeks to discuss the current landscape in resuscitation medicine-how we got here and where we are going.

Cardiac arrest in takotsubo syndrome: results from the InterTAK Registry

AIMS

We aimed to evaluate the frequency, clinical features, and prognostic implications of cardiac arrest (CA) in takotsubo syndrome (TTS).

METHODS AND RESULTS

We reviewed the records of patients with CA and known heart rhythm from the International Takotsubo Registry. The main outcomes were 60-day and 5-year mortality. In addition, predictors of mortality and predictors of CA during the acute TTS phase were assessed. Of 2098 patients, 103 patients with CA and known heart rhythm during CA were included. Compared with patients without CA, CA patients were more likely to be younger, male, and have apical TTS, atrial fibrillation (AF), neurologic comorbidities, physical triggers, and longer corrected QT-interval and lower left ventricular ejection fraction on admission. In all, 57.1% of patients with CA at admission had ventricular fibrillation/tachycardia, while 73.7% of patients with CA in the acute phase had asystole/pulseless electrical activity. Patients with CA showed higher 60-day (40.3% vs. 4.0%, P < 0.001) and 5-year mortality (68.9% vs. 16.7%, P < 0.001) than patients without CA. T-wave inversion and intracranial haemorrhage were independently associated with higher 60-day mortality after CA, whereas female gender was associated with lower 60-day mortality. In the acute phase, CA occurred less frequently in females and more frequently in patients with AF, ST-segment elevation, and higher C-reactive protein on admission.

CONCLUSIONS

Cardiac arrest is relatively frequent in TTS and is associated with higher short- and long-term mortality. Clinical and electrocardiographic parameters independently predicted mortality after CA.

Use of extracorporeal membrane oxygenation for eCPR in the emergency room in patients with refractory out-of-hospital cardiac arrest

Background

Out-of-hospital cardiac arrest (OHCA) refractory to conventional high-quality cardiopulmonary resuscitation (CPR) may be rescued by extracorporeal CPR (eCPR) using veno-arterial extracorporeal membrane oxygenation (V-A ECMO). Even when trying to identify eCPR candidates based on criteria assumed to be associated with a favourable neurological outcome, reported survival rates are frequently below 10%.

Methods

All patients undergoing implantation of V-A ECMO for eCPR between January 2018 and December 2019 (N = 40) were analysed (age 53±13 years; 75% male). Patients with refractory OHCA and potentially favourable circumstances (initial shockable rhythm, witnessed arrest, bystander CPR, absence of limiting comorbidities, age <75 years) were transported under mechanical chest compression. Candidates for eCPR should have a pH ≥6.9, arterial lactate ≤15 mmol/L and time-to-ECMO should be ≤60 minutes.

Results

Overall 30-day survival was 12.5%, with 3 of 5 survivors having a favourable neurological outcome (cerebral performance category (CPC) 1 or 2), representing 7.5% of the total eCPR population. No patient selected for eCPR met all pre-defined criteria (median of unfavourable criteria: 3). Importantly, time-to-ECMO most often (39/40) exceeded 60 minutes (mean 102 ±32 min.), and lactate was >15mmol/L in 30 out of 40 patients. Moreover, 22 out of 40 patients had a non-shockable rhythm on the first ECG.

Conclusions

Despite our intention to select patients with potentially advantageous circumstances to achieve acceptable eCPR outcomes, the imminent deadly consequence of withholding eCPR obviously prompted individual physicians to perform the procedure also in presumably more unfavourable settings, resulting in similar mortality rates of eCPR as reported before.